Posted On Thursday, July 9, 2015
As the healthcare industry feels a key wave of competition, major for-profit health insurance companies are beginning to fight for their immunity within the healthcare industry, avoiding ultimate elimination. Aetna recently announced their acquisition of health insurer, Humana, strengthening their survival skills for this competition. This $37 billion deal is the first of many expected mergers amongst United States healthcare giants.
Aetna and Humana have projected combined revenue of about $115 billion for 2015, which is a product of the company’s business with Medicare, Medicaid, Tricare, and other lucrative federal programs. The companies expect this deal to close in the second half of 2016, making them the second largest insurance company by sales, after UnitedHealth Group Inc. The CEOs of both Aetna and Humana explained how the merger makes sense within today’s healthcare market, considering Aetna and Humana have ‘complimentary customers’. Aetna handles a large and diverse commercial business while Humana handles an ever growing Medicare Advantage business.
While these acquisitions take place, there is worry for lack of innovation for new healthcare plans, along with questions of effectiveness when working with hospitals and doctors in order to deliver the most viable ways of health care. Bruce D. Broussard, president and chief executive of Humana, stated, “These are the two most innovative companies in the health care sector today”. Aetna and Humana plan to pursue the manner in which insurers are cooperating with providers. Mr. Bertolini also looks towards directing the company’s policy sales towards individuals, in addition to their traditional insurance provided for employers, as a direct result of the recent shift in the Medicare and Medicaid market.
Of course, the Securities and Exchange Commission, as well as the companies’ shareholders, must approve this acquisition, which can take several months. Aetna shareholders are projected to own about 74 percent of the combined company, while Humana shareholders would own 26 percent. Aetna plans to base their headquarters in Louisville, Ky., the current home of Humana, where they continue business with Medicare, Medicaid, and Tricare operations. Industry insiders are watching for the next merger partners to image.
Posted On Tuesday, July 7, 2015
On June 9, 2015, former Riverside General Hospital President Earnest Gibson III was sentenced by U.S. District Judge Lee H. Rosenthal of the Southern District of Texas to 45 years in prison after being found guilty of facilitating a $158 million Medicare fraud and kickback scheme. The extensive, six-year scheme involved the submission of false claims to Medicare for mental health treatment. Gibson III’s son, Earnest Gibson IV, the operator of Devotions Care Solutions, a satellite psychiatric facility of Riverside General Hospital, was sentenced to 20 years in prison, and Regina Askew, the owner of Safe and Sound group home, was sentenced to 12 years in prison for their roles in the Medicare fraud scheme.
Following a five-week jury trial, Gibson III, Gibson IV and Askew each were convicted of conspiracy to commit health care fraud, conspiracy to pay and receive kickbacks, as well as related counts of paying or receiving illegal kickbacks. Gibson III and Gibson IV also were convicted of conspiracy to commit money laundering. According to the evidence introduced at trial, the defendants submitted to Medicare, through Riverside and its satellite locations, approximately $158 million in false and fraudulent claims for outpatient psychiatric services. The evidence established that the beneficiaries for which the hospital billed Medicare weren’t qualified for or in need of the mental health services they were being given. The evidence further demonstrated that instead of receiving intensive outpatient treatment for severe mental illness for which Medicare was billed, patients rarely saw psychiatrists and were instead placed in front of television screens to watch movies.
The conspiracy did not end there – Gibson III and Gibson IV also paid kickbacks to patient recruiters, including Askew, to facilitate the fraud. In addition to their lengthy prison terms, Gibson III was ordered to pay restitution in the amount of $46,753,180, Gibson IV was ordered to pay restitution in the amount of $7,518,480, and Askew was ordered to pay restitution in the amount of $46,255,893. All three defendants have filed notices to appeal their sentences to the Fifth Circuit Court of Appeals.
Gibson III testified on his own behalf at trial, denying he had any knowledge of the wrong-doing at the heart of the government’s case. In an extensive interview given to the Houston Chronicle after his trial, Gibson III claimed that the government’s case was motivated by racism and a desire by others to obtain the hospital’s valuable real estate holdings in Houston’s Third Ward.
According to the Chronicle, Gibson III claimed that he was held to an unfair standard, “I was never accused of knowingly…getting a kickback. I was accused of ‘should have known’…That’s a tough burden. It’s not a fair burden for any American citizen. Either you know or you don’t. Either you benefited or you didn’t.”
In addition to the filing a notice of appeal of his conviction, according to the Chronicle, Gibson III has also filed a lawsuit, pro se, with the U.S. Court of Federal Claims, claiming that he was unjustly prosecuted and convicted.
